Tuesday, October 4, 2011

Okay, it's time again for you armchair neurologists out there to help me with a challenging case. Here is, verbatim, the first paragraph of my note. See if you can guess the diagnosis:

"When working outside in the Summer, or inside baking, she becomes warm, sweaty, and lightheaded. The symptoms resolve with drinking cold water and cooling down. They don’t occur if she keeps up on her fluid intake."

You'd better run about 100 tests to rule out all of the above. Then run them again, just to make sure. At which point, patient will see another doctor because you can't find anything "wrong", and my insurance rates will go up 10% this year.

Hmmm, that's a tough one. Better run 100 expensive tests to rule out all of the above. Then repeat, to confirm because patient forgot to mention meds she was taking during tests. Then, after trying about 20 different expensive medications, patient will go to another doctor because you can't find anything "wrong." Shortly after, my insurance rates will jump by 15%.

As a fellow neurologist I have experienced this too. Last month I was called by the ED about a young man who worked at a dry wall production plant where the temperature is hundreds of degrees. He reported he typically had to drink a gallon of fluids a day and sweated profusely at work. He was brought to the hospital after his second episode of passing out. The consult was for a positive Romberg and gait ataxia. I asked them three times to check orthostatic vitals, which they only did after I had seen him. After they were positive they still wanted to admit him to neurology!

I think she should stop working outside in the summer, at least until evening, and should stop baking unless and until her kitchen is air-conditioned. Please provide a billing address for my expert advice!

I have a few addition questions prior to making my official diagnosis... Does she get cold when standing infront of an open fridge? Does she get wet when she goes swimming? Does she find these symptoms bothersome or concerning?

If so, I would recommend introducing her to your patient who couldn't see when she closes her eyes, and encourage them to initiate a support group for the terminally stupid. Preferably in a location where Darwin's Theory could get a little help.

This is remarkable. If we've ruled in the possibility that fainting may require a valsava maneuver to relieve the excitation and stimulant effect of baking indoors and/or being outdoors--hot and sweatiness, then we'd want more info.

I would want more H and P, like what happens when she drinks water at room temperature, or hot water?

Or what happens if instead of drinking water, she drinks lemon squash.

This could very well be the acid-test.

What happens if she drinks water while sitting on a chair, on a couch or here or there? What happens if she drinks it anyhow, or anywhere?

The question for her, then, is not whether she has normal temperature-regulation to respond to ambient temperature, or even there's a snake skeleton in her closet, but how she likes her water.

In a tumbler or a glass, on the porch, or in the grass. And, whether drinking a four pints of Guinness would take care of it.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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